Is hospital admission for heart failure really necessary? The role of the emergency department and observation unit in preventing hospitalization and rehospitalization

Approximately 800,000 times a year, an emergency physician admits a patient with symptomatic heart failure (HF). Yet only a minority of emergency department patients with HF are severely ill as a result of pulmonary edema, myocardial ischemia, or cardiogenic shock. The majority of patients are not in need of an acute intervention beyond decongestion, and few patients during hospitalization undergo invasive diagnostic testing or therapeutic procedures that require intense monitoring. Although hospitalization is clearly an inflection point, marking a threshold that independently predicts a worse outcome, the exact impact of hospitalization on post-discharge events has not been well elucidated. Thus, large subsets of patients with HF are hospitalized without a clear need for time-sensitive therapies or procedures. The authors estimate that up to 50% of emergency department patients with HF could be safely discharged after a brief period of observation, thus avoiding unnecessary admissions and minimizing readmissions. Observation unit management may be beneficial for low-risk and intermediate-risk patients with HF as continued treatment, and more precise risk stratification may ensue, avoiding inpatient admission. Whether observation unit management is comparable with or superior to the current approach must be determined in a randomized clinical trial. Critical end points include time to symptom resolution and discharge, post-discharge event rates, and a cost-effective analysis of each management strategy. It is the authors' strong assertion that now is the time for such a trial and that the results will be critically important if we are to effectively influence hospitalizations for HF in the near future.